Healthcare Provider Details

I. General information

NPI: 1699617860
Provider Name (Legal Business Name): REVIVD RECOVERY AND WELLNESS FORT WAYNE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2026
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 E MAIN ST
FORT WAYNE IN
46802-1910
US

IV. Provider business mailing address

402 E MAIN ST
FORT WAYNE IN
46802-1910
US

V. Phone/Fax

Practice location:
  • Phone: 260-298-8297
  • Fax: 260-387-6154
Mailing address:
  • Phone: 260-298-8297
  • Fax: 260-387-6154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY BROWN
Title or Position: CEO
Credential: NP
Phone: 260-298-8297